Healthcare Provider Details

I. General information

NPI: 1194383802
Provider Name (Legal Business Name): ENEZIAH WALTERS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/29/2019
Last Update Date: 06/03/2026
Certification Date: 06/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

616 S CREYTS RD STE D
LANSING MI
48917-8269
US

IV. Provider business mailing address

134 W MAPLE ST
MASON MI
48854-1657
US

V. Phone/Fax

Practice location:
  • Phone: 517-512-5289
  • Fax:
Mailing address:
  • Phone: 517-676-9788
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number6801102859
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number6801108006
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801108006
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: